Home Office:

One Nationwide Plaza • Columbus, Ohio 43215 Administrative Office:

8877 North Gainey Center Drive • Scottsdale, Arizona 85258 1-800-423-7675 • Fax (480) 483-6752

EVENT/PARTY PLANNERS & COORDINATORS SUPPLEMENTAL APPLICATION

(Complete in addition to ACORD Application)

1. Name of Applicant:

2. Location of Premises: Does Applicant own or lease (long term) a hall/banquet facility? ................................................................ Yes No If yes, what is the square footage?

3. Types of Events (Show percentage of annual receipts by type of Event):

Event Percentage Event Percentage

Auto Shows Open Houses

Animal Shows—Cat, Dog, Horse, etc.

Political Gatherings, Conventions, Rallies*

Athletic Events/Exhibitions/Contests* Proms

Antiques & Collectibles Shows Includes Books, Coins, Comic Books, Stamps & Trading Cards

Meetings/Seminars—Type: (Under 150 People in attendance)

Corporate/Business

Private

Public

Auctions* Recitals

Baby or Wedding Showers Parties—Type:

Anniversary

Birthday

Dinner

Holiday

Office

Sporting Event—TV (i.e., Super Bowl)

Theme Other (Describe)

Bar/Bat Mitzvahs, Baptisms, Quincenera

Barbecues

Beauty Pageants

Boat Shows

Charity Events—Banquets, Socials, Dances

Cocktail Receptions

Church Gatherings

Computer and/or Electronic Fairs/Shows

Conventions/Trade Shows*—Type: (150 or more people in attendance)

Corporate

Trade

Industry

Picnics—Type:

Corporate—Employee Only

Corporate—Other

Private

GLS-APP-63s (11-06) Page 1 of 4

Events (continued)

Event Percentage Event Percentage Exhibitions—Inside* Reunions Exhibitions—Outside* Rodeos/Bull Fights* Fashion Shows RV Shows Festivals* Speaking Engagements Gun Shows Talent Shows/Contests Health, Science Fairs Theatrical/Movie Premiers Home and/or Garden Shows Weddings & Wedding Receptions

* Provide separate detailed narrative description of Events

Musical Events*

Event Music Type* Percentage Event Music Type* Percentage

Alternative Heavy Metal

Bluegrass Hip Hop

Classical and/or Chamber Music Jazz

Country/Western Rap

Gospel & Religious R & B

Gothic Other—Describe Type:

Hard Rock

* Provide separate detailed narrative description of Events

4. Number of Event dates planned for current year: Number of Event dates held last year: Average attendance per Event date: Maximum daily attendance per Event: Average length of Event (number of days):

5. Total Annual Receipts/Sales: $ Total Annual Cost of Subcontractors: $ Total Annual Payroll: $ Total Number of Employees:

6. Does the Applicant sponsor or promote any Events? ................................................................................. Yes No If yes, provide details:

7. Is Applicant involved in any other operations or business?......................................................................... Yes No If yes, describe:

GLS-APP-63s (11-06) Page 2 of 4

8. Services Provided (Indicate: Yes, No or N/A)

Additional Services Performed by Applicant & Employees

Provided by Subcontractors

Hired by Applicant

This Service not Provided

Automotive Tours—Bus/Jeep/Other

Booking Agent

Catering—Food & Non-Alcoholic Drink Only

Catering—Food & Liquor

Catering—Liquor Only—Bartender Service

Consulting Only—No other services provided

Construction—Setup and/or Take Down

Babysitting

Fireworks

Horseback Riding

Hot Air Balloon Rides

Maintenance/Janitorial Responsibilities

Rope Courses

Security Operations—Type:

Bodyguard/Personal Security

Bouncers/Crowd Control

Doormen

Parking/Traffic Control

Watchmen/Guard Service

Shuttle/Taxi/Limousine Service

Team Building Exercises—Indoor or Outside

Vehicle Valet Service

9. If work is subcontracted: Are certificates of insurance required from all subcontractors and vendors? ............................................. Yes No Is Applicant added as additional insured on subcontractors’ policy? .......................................................... Yes No Are Limits of Liability on subcontractors’ policy equal to or greater than Applicant's? ................................ Yes No Does Applicant ever use uninsured contractors or subcontractors to provide products or services for any Event? ................................................................................................................................................... Yes No

10. Hold-Harmless Agreements: Does the Applicant use a standard client contract, which outlines the specific responsibilities of the Applicant? .................................................................................................................................................... Yes No Do others hold Applicant harmless? ............................................................................................................ Yes No Does Applicant agree to hold any third party harmless? ............................................................................. Yes No Does Applicant assume, by contract or verbally, responsibility for any injury or damage that may occur during an Event? ............................................................................................................................... Yes No

GLS-APP-63s (11-06) Page 3 of 4

11. Equipment—Does the Applicant rent, furnish or install any of the following equipment? Amusement Devices Barricades Bleachers Dance Floors Folding Chairs/Tables Sound Equipment Stages/Staging Tents Portable Restrooms Space Heaters

12. Does Applicant have Workers’ Compensation coverage in force? ............................................................. Yes No Does Applicant lease employees? .............................................................................................................. Yes No

13. Does Applicant have Professional Liability coverage in force? .................................................................. Yes No

14. Does Applicant have Liquor Liability coverage? ......................................................................................... Yes No

15. Does the Applicant have a Web site? ......................................................................................................... Yes No If yes, provide Web site address:

16. Attach: (a) Any descriptive advertising literature; (b) Copy of Applicant's standard contract with clients; (c) Copies of all agreements in which the Applicant has assumed liability; and (d) Separate detailed narrative descriptions as required.

Contact Person:

Phone Number:

FRAUD WARNING:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

APPLICANT’S NAME AND TITLE:

APPLICANT’S SIGNATURE: DATE: (Must be signed by an owner, partner or executive officer)

PRODUCER’S SIGNATURE: DATE:

GLS-APP-63s (11-06) Page 4 of 4